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Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA |
The Answer: Should Podiatrists
Provide Free Care?
Last week I asked the question, “should podiatrists should provide free care?” I introduced a patient of mine, a 39 year-old MediCal (Medicaid) patient who needed a revisional ankle arthrodesis, after a failed prior attempt by another physician. If I did the surgery, I would not be paid.
I posed the following questions regarding my situation:
- Should I take on this patient?
- Should podiatrists provide free care?
My questions generated some very interesting and informative discussion on eTalk. If you haven’t read it, I would recommend taking a few minutes to do so. You’ll find the discussion fascinating with some well thought-out opinions.
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| Figure 1. Posterior and anterior clinical views demonstrating left calf atrophy, valgus heel, prominent medial malleolus and pain-free left hallux varus and digital deformities. |
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I promised to weigh in with my opinion (Lord knows I’ve never been one to hold back on my opinions!), but before we get to tha,t I wanted to show the patient’s clinical appearance and radiographs — for the sake of interest. Feel free to respond on etalk with your comments. How would you surgically manage this patient’s problem? To prevent too much confusion, this patient had a clubfoot posteromedial release, 2 tendoachilles lengthenings, and a subtalar fusion in the remote past--and her first attempted ankle fusion was performed with the staples shown and one threaded Steinman pin (previously removed) from proximal anterior to distal posterior. She also has an approximately 1 inch short left lower extremity.
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Figure 2. Weightbearing anteroposterior ankle radiograph showing retained hardware and valgus ankle nonunion. |
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Figure 3. Weightbearing left lateral ankle radiograph. Prior subtalar fusion evident. |
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Figure 4. Weightbearing left long leg calcaneal axial radiographs demonstrating valgus and laterally translocated calcaneus. Fibula deformity of unknown etiology. |
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Now, back to our discussion about free podiatric care. Listed below is a broad summary of the opinions posted by our readers.
Summary Opinions:
- Podiatric services should be provided for community good will, although this can be a frustrating patient population with a heavy risk of practice revenue loss and potential litigation.
- New physicians looking for Boards cases and establishing a practice may opt to treat non-noninsured patients while those established doctors may not want the headache.
- Refer to orthopedics at an academic institution.
- Other health care practitioners don’t treat patients for free (ex. dentists) so why should we?
- If you give away too much free care your services will be devalued because people put greater value on those things they pay for.
All in all, I agree with the majority of the opinions stated (each one in part). Let me start with number 3. Why would I send this patient to orthopedics? Why should the buck stop with them? Aren’t we the experts of the foot and ankle? If I did anything I would refer this patient to a podiatrist. It’s a poor reflection on us when we view orthopedics as the “go to” specialty.
Number 5 is an interesting and peculiarly capitalistic idea. Within this statement is the assumption that we only value those things for which we pay a lot of money. This is an unfortunate modern phenomenon, one in which I wholeheartedly disagree. For the sake of brevity, I’ll point out one historical example: Harvey Cushing, MD. Cushing may be currently known today for the endocrine diseases that bear his name, but he was known in the early 1900’s as the father of neurosurgery and was arguably the single most skilled surgeon in the world – and he saw the majority of his patients for free or at a significant discount. At that time, it seems, a surgeon was valued for his work rather than for how much money he charged. If number 5 really is true today, then that’s truly sad. I won’t practice this way.
One of the reasons I enjoy working for larger organizations (previously a hospital and now a university) is they can absorb, to some degree, the expense of caring for patients with little or no health insurance. With that being the case, I don’t have to worry as much about getting paid. I personally receive a paycheck regardless of whether or not this patient is profitable for my employer. Obviously, there are limits to how much charity care any one organization can sustain. Where that limit is I’m not sure, and it’s up to smarter people than me to determine. Now, clearly if I were in a small private practice the idea of taking on an uninsured major reconstructive patient with the attendant long term follow-up expenses would not be tolerable. As such, I would refer this patient to my nearest teaching hospital podiatric service.
What about the potential for litigation? First, I told myself four years ago, when I started practice, that I would not treat patients based on the fear of being sued. That means (apart from the red flag patients), I will not consider the specter of a lawsuit when determining care for my patient. If that gets me sued, then so be it. I won’t live in fear.
Second, after performing a reasonably thorough search I have been unable to find any study or data that definitively shows uninsured patients are more likely to sue their doctors. If one of our readers can prove this to be true, please post it on the eTalk, and I’ll reconsider my viewpoint. Even if it’s true that the uninsured are more likely to sue their doctors, I might ask: why bother doing any surgery at all? I’m sure most of our readers agree that most podiatrists are sued as a result of surgical cases, rather than nonsurgical. If, then, the risk of litigation after surgery is so much greater yet we still do surgery, why shouldn’t the same reasoning process apply to under- or uninsured patients? If you’re so afraid of being sued, stop doing surgery.
Call me naïve or call me stupid (I’ve been called worse many times), but as long as I consider myself this patient’s best chance for treatment, and it wouldn’t significantly adversely affect my practice, then I’ll treat her.
Having said all that, the reality of the situation is that because I’m not a network provider for her MediCal HMO, if I did her surgery she would be liable for the entire hospital bill -- even if I waived my own surgical fees. I’ve spoken with the referring doctor who is working with the patient to obtain Medicare disability and plans to have her follow-up with me if this succeeds. It seems with all the impassioned arguments, it all boils down to the dollar.
My thanks to those who’ve contributed to the PRESENT eTalk conversation. Your arguments spur our thoughts and improve our practice of medicine. Let’s continue the conversation online! Best wishes.
Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum. Best wishes.
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
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